New warningover deathsfrom syringes

A whistleblower has warned that the common use of a type of automatic syringe by the NHS could have resulted in widespread premature deaths among elderly patients.

The devices, used to deliver drugs including powerful opiate painkillers, were permitted to be used until 2015, despite warnings over the risk of fatalities from user error going back to the 1990s.

Doctors had warned that confusing two models of the infusion pumps could lead to a day’s dose of drugs being delivered in one hour.

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The whistleblower on the government inquiry into hundreds of deaths at the Gosport War Memorial Hospital spoke to the Sunday Times after the panel’s report was limited in its findings on the devices.

‘Anyone who has lost their granny over the past 30 years when opiates were administered by this equipment will be asking themselves, “Is that what killed Granny?”’they told the paper.

A 2008 paper by the NHS’s now-defunct Purchasing and Supply Agency (PSA) said the devices were an ‘essential component of palliative care’.

Around 40,000 of the devices — a quarter of the worldwide total — were in the UK, the majority in primary care.

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Doctors had raised concerns over the Graseby MS26 and Graseby MS16A after cases emerged of the devices, known as drivers, causing dangerous over-infusion of drugs because of confusion caused by differences in their function.

The PSA said the devices, which appeared ‘very similar aside from colour’, delivered drugs at different rates.

Hazard notices were issued by the Medicines and Healthcare products Regulatory Agency (MHRA) and its predecessor, the Medical Devices Agency (MDA), to ensure NHS staff knew the difference between the models.

A damning report released this week said more than 450 people had their lives shortened after being prescribed powerful painkillers at Gosport War Memorial Hospital.

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The report said: ‘The panel has considered issues concerned with the particular syringe drivers, known by their tradename of Graseby, and is aware of the hazard notices which applied. The panel’s analysis does not rest upon any issue relating to these notices.

A Department of Health and Social Care spokesman said: ‘While there is a range of statutory requirements to monitor and improve safe management and use of controlled drugs, we would not hesitate to take further action to improve safety.”

The report added: “Currently, there are safer alternatives to the MS26/MS16A drivers on the UK market; two of which comply with (the IEC standard).”

Of four brands of syringe drivers compared by the PSA, those made by Graseby were the cheapest to run.

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A hazard notice issued by the Scottish NHS in 1994 warned of the risk of death from incorrect rate setting due to confusion between the two models.

“Incidents continue to be reported in which confusion between Graseby Medical MS16A and MS26 ambulatory syringe drivers has led to incorrect infusion rates being set, resulting in serious over-infusion and fatality,” the notice said.

Meanwhile the National Archives holds records of an MDA safety notice being issued over the pumps in 1995.

In the late 2000s, Australia and New Zealand had programmes to remove the MS devices from use, although there was no similar central initiative in the UK.

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In 2011, the National Patient Safety Agency recommended that all Graseby syringe drivers should be withdrawn by 2015, however it stopped short of a mandatory recall.

A damning report released this week said more than 450 people had their lives shortened after being prescribed powerful painkillers at Gosport War Memorial Hospital.

An additional 200 patients were “probably” similarly given opioids between 1989 and 2000 without medical justification.

The report said: “The panel has considered issues concerned with the particular syringe drivers, known by their tradename of Graseby, and is aware of the hazard notices which applied. The panel’s analysis does not rest upon any issue relating to these notices.”

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A Department of Health and Social Care spokesman said: “While there is a range of statutory requirements to monitor and improve safe management and use of controlled drugs, we would not hesitate to take further action to improve safety.”